About Shirie Leng, MD

I am a doctor. I know how the system works. I want to share ways of navigating the health system that will save people alot of aggravation. I'm an anesthesiologist at a large academic medical center. I'm also interested in the history of medicine and the development of the relationship between law, regulation, and medicine

When I was a young violin student I had to change violin sizes at various times as I grew. Each time felt funny, and each time my teacher would say “You’ll get used to it”. The Affordable Care Act, i.e ACA, i.e Obamacare, is now hated by fewer people. Only 43% of Americans oppose it, down from 53%. Pundits are saying this is because the recent open enrollment period went smoothly. That may be true, but if we take a lesson from history we can see that slow acceptance of the ACA is to be expected. We’ve gotten used to it.

Take, for example, the New Deal. The New Deal was a set of laws enacted in the wake of the Great Depression. These laws resulted in policies and institutions such as the FDIC, the criminalization of child labor, the Fair Labor Standards Act that established the 40 hour work week, and Social Security. Most people today would consider much of the New Deal to have been a pretty good idea. But that was not the case in the 1930s when these laws were passed. Rich people didn’t like it. Republicans didn’t like it (they thought the Social Security Act smacked of socialism. Funny, huh?). Conservatives thought there was too much infringement on individual rights. A third of the public didn’t like it, as judged from the 1936 election. Doomsday predictions claimed that the legislation would take away human rights, create too much big government, and ruin the constitution. Some would still argue that these predictions came true to some extent, but no one wants a repeal of child labor laws, and Social Security is now a political third rail.

In the case of the ACA, the opposition has been remarkably similar. Infringement on individual rights, states rights, big government, socialism, unconstitutionality, all these accusations have been thrown at the ACA. Additionally we have been told that the ACA would bankrupt the government, limit physician choice, and establish death panels. Some of these claims are still under review. But health care spending has gone down, more people have access to health care, and no death panels have materialized.

Parts of both the New Deal and the ACA either didn’t work or were deemed unconstitutional. But some parts stayed, and eventually became part of life in America. People got used to it. Just as people are getting used to the ACA.

As Congressional Republicans are acutely aware, it is much easier to prevent something from happening than it is to take it away once it has happened. This fact is based in the human tendency to give much more weight to loss than gain. We see this in end-of-life discussions, where doctors find it is more painful for families to decide to remove life support than to decide not to institute it. Such tendencies can be positive or negative. At work it is well known that once a new rule gets instituted we’re stuck with it; a rule, once made, is virtually impossible to get rid of, even if it doesn’t have the desired effect. Standardized testing in public schools is here to stay too, even though such testing has been shown to be a poor measure of real learning. On the other hand, a rule that works and makes sense, like a seat belt law, will also never go away, and eventually people get used to it and lives are saved. Once people got used to Social Security it became impossible to take it away. Once people get used to having insurance it will eventually become impossible to take it away.

Once something becomes status quo people tend to forget what they were so worried about.

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Thanks to our Dear Leader for the link to the Republican’s health reform proposal, cutely called PCARE. Professor Wright is the expert and will look through it carefully and give you the real scoop. I’ll be the opening act. I’ve read through it, and there are some good things in it, although you have to skip the rhetoric spouted in the first few paragraphs of every section. To wit: “Despite promises that Obamacare would lover health care costs, costs continue to skyrocket for patients, families, taxpayers, and businesses.” Actually, the Kaiser Family Foundation says that Medicare spent $1000 less per person last year, and is projected to remain steady at 14.5% of the federal budget and 3% of GDP. Non-partisan this treatise is not.

The good:

1. There is a proposed provision for extending health insurance policies across state lines. This would certainly help equalize coverage quality and could promote competition. It is worker-friendly and makes sense. Medicare is already nationwide, although the private insurance companies that actually provide a lot of the policies are not. So, OK. I wonder, though, since as I point out below the plan lays an awful lot of the responsibility for all of this stuff on the states.

2. The republicans like health care savings accounts, or HSAs (personal responsibility and all that) and would like to expand this option. Great as long as you have two coins to rub together at the end of the month.

3. They want to keep the coverage for kids under their parent’s plan ’til age 26. I guess that one polls well.

5. Transparency. “…health insurance plans would be required to disclose covered items, drugs, and services, any plan limitations or restrictions, potential cost sharing, the actual cost of services (my boldface), the claims appeal process, as well as the providers participating in the plan.” Some of this is already required, but some real information about cost would be welcome.

The not-so-good:

1. The plan throws out the rule that insurance companies cannot charge elderly patients more than 3 times what it charges a young person. This is considered “too restrictive” and the new proposal ups the number to 5 times. This is supposedly better because premiums would go down for millions of Americans. That it will also go up for millions of Americans is not mentioned.

2. The proposal seems to throw the ball back into the state’s courts. States can opt out of the coverage for kids under age 26, they can adjust the amount the elderly pay in comparison to the elderly, re-using the high-risk pool idea within states, and making the states negotiate the terms of cross-border agreements. Perhaps most oddly, it asks the states to designate health plans that would be the default coverage for people who don’t choose a plan. Wait, weren’t most states perfectly happy to let the federal government set up the health insurance exchanges?

3. The republicans also really like using tax credits, which I think have already been tried. Many times.

4. Here’s the part that makes me nervous. I quote:

“Under our plan, no one can be denied coverage based on a pre-existing condition. To help consumers with pre-existing conditions our proposal would create a new ‘continuous coverage protection’. Under this new protection, individuals moving from one health pan to another could not be medically unwritten and denied a plan based on a pre-existing condition if they were continuously enrolled in a health plan. This new consumer protection helps incentivize responsible behaviors by encouraging consumers to keep their health coverage.”

Those italics are not mine. People with pre-existing conditions who have been uninsured would supposedly get a grace period in the form of a one-time enrollment period in which they could not be denied for a pre-existing condition. So people who are not “responsible” (here read “poor”) aren’t entitled to this so-called consumer protection. I could be wrong about this, but I need a much better explanation about why the ACA’s rule that you can’t turn anyone down for a pre-existing condition at any time is so bad.

So there you go! The real health policy expert will now take the podium…

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Ever heard of the “plain meaning” rule? It is not, as I first thought, an admonishment to toddlers to speak clearly, although that would be an awesome, albeit unenforceable, rule. It is actually a real legal term that refers to a requirement that statutes under consideration by the courts generally be interpreted in accordance with their plain meaning. In other words, Congress has said exactly what they mean. Which it always does, of course.

The “plain meaning” rule, though, has an exception for absurdity. This exception permits a court to depart from the plain meaning of a statute when the result would be an absurd one that Congress could not possibly have meant. Hmm.. Second Amendment anyone? But I digress. The question, though, is how “absurd” a result must be before the exception kicks in. The Supreme Court has kept the exception narrow, one presumes to avoid completely absurd chaos stemming from the meaning of the word “absurd”.

Since we all know that Congress is generally acknowledged to be absurd, by whatever definition you choose, why am I talking about this? Because the Supreme Court is set to hear a case that challenges the Affordable Care Act and the decision could hinge on the plain meaning rule. The case concerns tax subsidies that currently help millions of people afford health insurance under the law. The New York Times says as much as 87% of people who got insurance coverage through Healthcare.gov were eligible for subsidies. The central question in the case, King v. Burwell, No. 14-114, is how to interpret a provision in the law limiting subsidies to “an exchange established by the state.” The challengers say the provision means that only people in states with their own exchanges can get subsidies. Since most states opted to let the federal government set up the exchanges, all the people in those states wouldn’t be eligible. In states like Mississippi that’s like 95% of all newly insured folks.

Michael Rosman, a blogger for the SCOTUS blog, explains it like this: “…the statute in question plainly provides that, in calculating the size of a subsidy, one must begin with the monthly premium of a qualified health plan offered in the individual market within a state that someone enrolled in ‘through an Exchange established by the State under Section 1311 [of the ACA].’ “State” is a defined term under the Act and plainly does not mean the federal government. In King, the federal government does not seriously argue that it would be absurd for Congress to limit subsidies to individuals in states that have state-operated exchanges (although it does argue strenuously that that is not what Congress meant). Rather, it suggests that there are other provisions of the ACA that would be rendered absurd if the phrase ‘Exchange established by the State’ were given its plain meaning. (Whether an absurdity in a different provision should be sufficient to reinterpret a phrase away from its plain meaning in the relevant section is another question).”

Clear as mud. The name Burwell in the title of the suit would be Sylvia Matthews Burwell, the Secretary of Health and Human services. As to King, that would be David King et. al, one of a group of four residents of the state of Virginia who don’t want to purchase insurance coverage. At all. From any source. So for Mr. King, if subsidies were not available he would be exempt from the requirement to get coverage and thus also from the tax penalty. With the subsidies, the coverage is theoretically affordable and thus he would have to pay the tax penalty if he isn’t covered.

This case is brought by four people who don’t want to pay for stuff. Why is the Supreme Court getting involved? Because of the supporting appellants: Senators John Cornyn (R, Texas), Ted Cruz (R, Texas), Orrin Hatch (R, Utah), Mike Lee (R, Utah), Rob Portman (R, Ohio), Marco Rubio (R, Florida), representative Darrell Issa (R, California) and the states of Oklahoma, Alabama, Georgia, West Virginia, Nebraska, and South Carolina, all staunchly republican states that have rejected medicaid expansion (except West Virginia) and state-run exchanges. For most of the residents of these states removal of the subsidy would likely leave them back in the ranks of the uninsured.

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In researching a novel I am writing I have been reading about the history of the treatment of depression. As often happens, I ran into an historical issue with echoes of the future.

Here’s an interesting paragraph from Howard Kushner’s book American Suicide.

“While asylum superintendents [in the 1840s] were as much captive of bourgeois ideology [the conviction that the insane could be reformed and that the suicidal could be cured] as were other social reformers, they were influenced on a daily basis by more parochial concerns. Not least of all, these men sought stable employment in the medical profession at a time when, buffed by competing medical sects, medicine promised neither prestige nor a regular income. A career as an asylum superintendent offered a solution to the contradictions between humanitarian desires to help others and a quest for economic security. Like most professionals then and now, these asylum physicians saw no conflict between an increase in their professional power and the improvement of the condition of the patients they served. Indeed, they viewed the former as essential for the latter.” (Bold letters are my addition.)

Let’s look at that second-to-last sentence. Professional physicians see no conflict between increases in power and the improvement of patient condition. Conflict may not be quite the right word. Maybe correlation is a better one. Professional physicians see correlation between increases in power and improved patient condition. Up to a point the statement is historically accurate. There was no conflict in the eighteenth and early nineteenth centuries because as trained doctors from legitimate medical schools began to have more influence than the untrained barber-surgeons and apothecaries, patient health did get better. Education and science eventually led to treatments that truly helped people. This resulted in a medical profession which, unlike that of 1840, had great prestige and good income.

Since those early days of medical professionalization, however, power has shifted. The turn away from paternalism toward autonomy has shifted the balance. Regulation, legislation, and an omnipresent media have shifted it further. Power, which used to be in the hands of doctors, for better or worse, is now in the hands of regulators, administrators, and the patients themselves. The question is, does the decrease in physician power correlate with a change in the health of patients?

The answer, of course, depends on who you ask.

You could ask Timothy Quill and Howard Brody, who would tell you they doubt extremes of patient power increase the well-being of patients. In 1996 they wrote the following in the Annals of Internal Medicine: (Ann Intern Med. 1996;125(9):763-769)

“At one extreme end of this [patient autonomy] spectrum is the “independent choice” model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician’s exercise of power and influence inevitably diminishes the patient’s ability to choose freely.”

You could ask the Physician Regulatory Issues Team at CMS, which claims that the power of regulation, in the form of government money, improves the condition of patients:

“Physicians have a special role in our health care system, as they not only care for the health of individual patients, but also help to shape the broad health care delivery system. As the federal Medicare agency, CMS respects the bond of trust between physicians and their patients, and appreciates the need to support physicians in the leadership they provide in service delivery. The Medicare program and physicians share a common mission, the provision of high quality medical care for patients.” (http://www.cms.gov/Outreach-and-Education/Outreach/PRIT/index.html?redirect=/prit/)
You could ask Drs Bell, Wilkes, and Kravitz, who may say that the power of advertising is not improving anyone’s condition. They found that “A sizable fraction of patients believed they would react negatively if their physician refused to provide a prescription for a drug advertised in the general media.” The Journal of Family Practice [1999, 48(6):446-452]
You could ask Louis Goodman and Tim Norbeck of Forbes, who would probably say that regulations are not increasing patient health. “…Physicians are already spending 22 percent of their time interacting with insurers on formularies, claims, billing, credentialing, pre-authorizations, and quality measure data. The workload can only increase with the new [ICD-10] codes.” http://www.forbes.com/sites/physiciansfoundation/2013/11/05/healthcare-is-turing-into-an-industry-focused-on-compliance-regulation-rather-than-patient-care/

You could ask the people of Florida, where doctors abuse their power of the prescription pad. They would say that absolutely, regulation has improved the condition of patients. An article in the New York Times reported that “New laws are also cutting off distribution [of prescription painkillers]. As of July, Florida doctors are barred, with a few exceptions, from dispensing narcotics and addictive medicines in their offices or clinics. As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year.” http://www.nytimes.com/2011/09/01/us/01drugs.html

Balance of power is important in health care, just as it is in government and marriages. No one will argue that giving physicians full power to do anything they want is a great idea. But we need to be careful about how much power we take away.

A brief history: in 2008-2009 two acts created the incentive program for implementation of EHR that resulted in the Meaningful Use requirements: HITECH (Health Information Technology for Economic and Clinical Health), and ARRA (American Recovery and Reinvestment Act). The idea was that doctors who billed Medicare and Medicaid could get financial incentives to help them install EHRs in their practices, but only if the EHR and the doctor both ensured CMS that the EHR had “meaningful use”, i.e, that it did what CMS wanted it to do. It was supposed to be a phased-in process, and stage 2 requirements are more stringent than stage 1.

AMA board chair Steven Stack says that the AMA “has provided ongoing input since the inception of the EHR incentive program and has urged greater flexibility to make the program more reasonable and achievable for physicians.” This is sort of true. On March 15, 2010 AMA executive vice president and CEO Michael Maves wrote a letter to then-head of Health and Human Services Kathleen Sibelius. In it he said the following:

“On behalf of the physician and medical student members of the American Medical Association (AMA), I appreciate the opportunity to provide comments on the Department ofHealth and Human Services’ (HHS) interim final rule (IFR) on an initial set of standards, implementation specifications, and certification criteria for electronic health records (EHRs). The AMA recognizes that an initial set of EHR standards, implementation specifications, and certification criteria are required to ensure that certified EHR technology is capable of supporting the achievement of meaningful use by physicians and other eligible professionals(EPs), as specified under the Medicare and Medicaid EHR incentive programs, beginning in 2011.”

Translation: Yeah, yeah, yeah, we understand you need to make sure you’re getting what you’re paying for. We don’t like it, but we get it.

Then Maves goes on to the next sentence:

“Not only must EHR technology be “certified” to meet the meaningful use incentive requirements, but EHRs must also adequately meet a practice’s specific workflow and clinical needs.”

A still, small voice, as the Bible says. Translation: “But…what about us?” This particular sentence seems to have gotten lost in the political soup.

Last week, the American Hospital Association and the American Medical Association sent a joint letter to HHS Secretary Kathleen Sebelius asking for greater flexibility in the requirements of the meaningful use program:

“We appreciate the Department of Health and Human Services’ (HHS) decision to extend Meaningful Use Stage 1 through 2014. Physicans and hospitals have made significant investments in health information technology (IT), which is evidenced by the increasing numbers of providers who are using EHRs and attesting to Meaningful Use. We also share the administration’s commitment that no providers – or the patients they serve – are left behind as we proceed to Stage 2. However, our members, and the vendors they work with, report growing concerns that the rapidly approaching start date for Stage 2 is on a trajectory that will not provide enough time or adequate flexibility for a safe and orderly transition unless certain changes are made.”

Translation: The beatings will continue until morale improves.

The AMA has created a new framework for usability. At least, they’re calling it new. The rest of us have known this stuff for years. Things like this:

1. Poor EHR design gets in the way of face-to-face interaction with patients because physicians are forced to spend more time documenting required information of questionable value. Features such as pop-up reminders, cumbersome menus and poor user interfaces can make EHRs far more time consuming than paper charts. Amen.

2. Current technology often requires physicians to enter data or perform tasks that other team members should be empowered to complete. No kidding.

3. Transitioning patient care can be a challenge without full EHR interoperability and robust tracking. Yup.

4. Few EHR systems are built to accommodate physicians’ practice patterns and work flows, which vary depending on size, specialty and setting. Preach it!

5. Although physicians spend significant time navigating their EHR systems, many physicians say that the quality of the clinical narrative in paper charts is more succinct and reflective of the pertinent clinical information. A lack of context and overly structured data capture requirements, meanwhile, can make interpretation difficult. Yes.

6. Data “lock in” is a common problem. EHR systems should facilitate connected health care across care settings and enable both exporting data and properly incorporating data from other systems. The end result should be a coherent longitudinal patient record that is built from various sources and can be accessed in real time. Bring it to me Lord!

7. The meaningful use program requires physicians to use certified EHR technology, but many of these products have performed poorly in real-world practice settings. Ya think?

“Physicians believe it is a national imperative to reframe policy around the desired future capabilities of this technology and emphasize clinical care improvements as the primary focus,” says Dr. Stack. What would have been nice is if the AMA had pushed harder back in 2008 for regulations regarding usability and opposed regulation regarding meaningful use a little more.

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I’m back, after an August filled with children, swimming, anniversaries and weddings. Two weekends in a row of travel and I’m glad to be home. Which reminds me of a subject I have long wanted to write about: The Medical Home.

Here is how the US Department of Health and Human Services describes The Medical Home (TMH for short): “The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.” AHRQ says that medical homes provide care that is Comprehensive, Patient-Centered, Coordinated, Accessible, and has Quality and Safety measures.

Here’s how the Patient-Centered Primary Collaborative defines TMH: “The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient’s needs.” The collaborative claims improvements in cost, utilization, population health, prevention, access to care, and patient satisfaction.

If all this sounds familiar, that’s because it is essentially a re-wording of the push to control costs by having care channeled through primary care doctors back in the early 2000’s. That initiative, widely implemented, resulted in a lot of jobs for paper pushers but not a lot of cost savings. In fact, the idea of a medical home has been around since at least 1967, especially in the field of pediatrics. I am not against the concept; the goals are all laudable. The problem is that “home” means different things to different people.

The Medical Parasite Host: If you live in a rural area, your medical home likely consists of one guy, or girl. That MD or NP does everything. That person is your home.

The Medical Grass Hut: In this home, everybody sits on the dirt floor and shares everything. This happens in poor communities where a visit to the doctor takes all day and everyone hangs out in the waiting room with their kids and grandparents, sharing two overworked doctors and a medical student. You pay with chickens or potatoes.

The Medical Motel Room: This is where you stop in for some low-quality, one-the-go health care. Like stand-alone clinics, urgent care centers, and pharmacies. It’s quick, it’s cheap, and no one knows you were there.

The Medical Project: Better than a grass hut. It still takes all day to see a doctor, but now you have bathrooms.

The Medical Apartment: Here you get your own doctor. Until your employer changes your insurance coverage. Then you move and find another doctor. It works as long as your medical problems fit in the back of a Ford Escort.

The Medical Single Family Home: Its nice, its comfortable, its stable, you’re insured. You have to drive into the city for your comprehensive, patient-centered, coordinated, accessible, quality healthcare, run by a healthcare conglomerate, but you have a car. Or know someone who does.

The Medical Mansion: You get all the care you want, when you want it. It’ll cost you, but it’s worth it because you don’t have to wait like everyone else.

The Medical Estate: The doctors come to your house. With MRI machines in trailers.

The Medical Home is a nice idea, and it works well in areas of the country where people are insured and have reliable transportation to centers that provide all the services TMH promises, that is, people in the middle. Rich people can buy their homes. Poor people either have low-quality homes provided for them or have no home at all. They drag their health problems with them from place to place, staying in motel rooms when they can, visiting the grass hut when they can’t. The ACA is trying to get everyone into at least an apartment. Even if it’s in a bad neighborhood.

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Brad Wright, Our Dear Leader, wrote a wonderful piece yesterday discussing the price of health care, using designer brands as examples. This caught my eye, of course, because I am as much a sucker for a $250 wallet that says “Burberry” on it as the next guy. ( Or a $1000 pair of shoes by Manolo, or a $100 T shirt by James Perse, or… What was I saying?) In the course of research I’m doing for a project on the career choice between nursing and medicine I have done some reading on how we make choices in general. One of these books, Predictably Irrational, by Dan Ariely, has a chapter titled “The Power of Price” which discusses some of the same issues Dr. Wright wrote about. So, with Brad’s permission, I’d like to examine the psychological impact of price a little further.

Let’s start with placebos, as Mr. Ariely does. When I was a new nurse I had an elderly patient who refused to go to sleep without pharmaceutical assistance. After indulging him with chloral hydrate for a couple of weeks (this was the 1990s), the deleterious side effects of giving this medication to elderly patients became apparent and his team decided to discontinue the sleeping pills. We nurses bore the brunt of this decision, as usually happens. One night, after the 16th call for sleeping pills from this gentleman, I got fed up and brought him a Tylenol. The patient took the pill and slept all night. It wasn’t the action of a specific medication that helped him sleep, but the act of taking a pill he expected to make him sleep.

Many of the financial decisions we make are based on this placebo effect, which runs on advertising, essentially. Instead of feeling better because we expect to, we pay more because we expect the more expensive option to be better. As Brad said, we expect an expensive wallet to be of better quality than a cheap one, because we equate price and quality. That this relationship does not necessarily exist has little bearing on our choices. I bought a shirt for a couple hundred bucks from The Row, and another shirt almost exactly the same from Ann Taylor Loft. Both shirts got holes in them. In the case of the expensive shirt I assumed this was what it was supposed to do – the “distressed” look, maybe. The other, cheaper shirt I assumed was just poor quality. We do the same thing with healthcare spending. If it costs a lot and has a brand name, it must be better. If the pharmacy gives a patient the generic and the medication doesn’t work, it’s because the pills themselves are no good. If the patient then gets the brand-name version of the exact same drug, there’s a good chance it will work better because she expects it to work better.

Mr. Ariely and some colleagues actually ran an experiment very much like my little attempt to help a man sleep. They gave a bunch of people a painful sensation, then gave them a drug with a fancy name that the subjects were told was an innovative new painkiller, then gave the subjects the painful stimulus again. The subjects felt less pain the second time, even though the drug was really just a vitamin C tablet. But here’s the interesting thing. When the subjects were told the painkiller was expensive, they were twice a likely to experience pain relief than if they were told the drug was cheap. As Mr Ariely says, “Price can change the experience”.

Now, in healthcare most of the time the consumer, i.e the patient, doesn’t know the price of the pill or treatment or test he’s getting. Nor does he necessarily care because he’s not paying for it. So patients use surrogate markers of price. Say I’m presented with two wallets and asked to choose one. I’m told I can get either wallet for free. One is soft brown leather with lots of pockets. The other has a lower quality leather and no pockets but has “Dior” emblazoned on it. According to Ariely’s research, and personal experience, most people will choose the Dior wallet, assuming it is of better quality. Patients do this with healthcare resources all the time. They go to Brigham and Women’s instead of Milton Hospital because Brigham is famous and has an Harvard affiliation. A patient wants an MD anesthesiologist instead of a CRNA because the person with the more expensive education must be better. Another has back pain and gets both a CT and an MRI, which makes her feel good that she’s getting such high quality care, two imaging tests being better than one. The actual quality of the care might be exactly the same, and the outcomes may be the same, but the expectations change the experience. This is why it’s so hard to cut wasteful spending.